Use of extracorporeal treatments in the management of poisonings

[Extracorporeal treatment in poisoning]

In rare cases, intoxicated patients may require an extracorporeal procedure for enhanced toxin elimination. The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup provides consensus- and evidence-based recommendations regarding the use of extracorporeal procedures in the management of critically ill, poisoned patients, with ongoing updates. Extracorporeal clearance is highest for low molecular weight substances with low volume of distribution, low plasma protein binding, and high water-solubility. To maximize the effect of extracorporeal clearance, blood and dialysate flow rates should be as high as possible, and the membrane with the largest surface area should be utilized. Intermittent hemodialysis is the most commonly employed extracorporeal procedure due to its highest effectiveness, while hemodynamically compromised patients can benefit from a continuous procedure.

Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit

Poisoning and its aftermath are globally observed and acknowledged concerns. India has a large burden of "self-harm/suicides" with 12.4/per 100,000 population committing suicide. Consumption of poisonous substances is the second most common mode of self-harm in India. Patients present to both public and private institutions in a critically ill state. The Indian Society of Critical Care Medicine (ISCCM) and Indian College of Critical Care Medicine (ICCCM) decided to address common and contentious issues related to poisoning by developing a position statement that is expected to be appropriate in the Indian scenario by the constitution of an "expert group" to provide a "set of statements" aimed at addressing the common issues faced by intensivists in their practice in managing such patients. The structured approach, framework, and process adopted in developing the position statement on the approach to poisoning have been detailed in this statement. The formation of an expert advisory panel was followed by a literature search, and multiple sessions of consensus-building exercises to reach the current statement presented below. The statement consists of relevant questions with possible answers thereof. Each answer was further weighed against the data and evidence available in the literature. Recommendations were made using a simplified score to make the statement qualitatively meaningful.

How to cite this article

Rungta N, Ray B, Bhalla A, DP Samaddar, Paul G, Prasad S, et al. Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit. Indian J Crit Care Med 2024;28(S2):S217-S232.

A Strategy for Rescuing a Child From Clonazepam Poisoning: A Case Study

BACKGROUND

This report describes the successful rescue of a 12-year-old girl who ingested large quantities of clonazepam tablets.

METHODS

The patient was promptly treated with flumazenil and hemoperfusion to alleviate the symptoms of central depression. Therapeutic drug monitoring was used to evaluate detoxification efficacy. The authors analyzed the rescue protocol for clonazepam poisoning based on the pathophysiology, clinical manifestations, and pharmacokinetics of clonazepam overdose.

RESULTS

The patient responded well to the treatment and was discharged from the hospital without adverse events.

CONCLUSIONS

This case study demonstrated the effectiveness and safety of combining flumazenil with hemoperfusion as a treatment for clonazepam poisoning. This study aimed to provide insights into more effective methods for treating clonazepam overdose and contribute to the ongoing issue of managing this condition.

Prediction the prognosis of the poisoned patients undergoing hemodialysis using machine learning algorithms

BACKGROUND

Hemodialysis is a life-saving treatment used to eliminate toxins and metabolites from the body during poisoning. Despite its effectiveness, there needs to be more research on this method precisely, with most studies focusing on specific poisoning. This study aims to bridge the existing knowledge gap by developing a machine-learning prediction model for forecasting the prognosis of the poisoned patient undergoing hemodialysis.

METHODS

Using a registry database from 2016 to 2022, this study conducted a retrospective cohort study at Loghman Hakim Hospital. First, the relief feature selection algorithm was used to identify the most important variables influencing the prognosis of poisoned patients undergoing hemodialysis. Second, four machine learning algorithms, including extreme gradient boosting (XGBoost), histgradient boosting (HGB), k-nearest neighbors (KNN), and adaptive boosting (AdaBoost), were trained to construct predictive models for predicting the prognosis of poisoned patients undergoing hemodialysis. Finally, the performance of paired feature selection and machine learning (ML) algorithm were evaluated to select the best models using five evaluation metrics including accuracy, sensitivity, specificity the area under the curve (AUC), and f1-score.

RESULT

The study comprised 980 patients in total. The experimental results showed that ten variables had a significant influence on prognosis outcomes including age, intubation, acidity (PH), previous medical history, bicarbonate (HCO3), Glasgow coma scale (GCS), intensive care unit (ICU) admission, acute kidney injury, and potassium. Out of the four models evaluated, the HGB classifier stood out with superior results on the test dataset. It achieved an impressive mean classification accuracy of 94.8%, a mean specificity of 93.5 a mean sensitivity of 94%, a mean F-score of 89.2%, and a mean receiver operating characteristic (ROC) of 92%.

CONCLUSION

ML-based predictive models can predict the prognosis of poisoned patients undergoing hemodialysis with high performance. The developed ML models demonstrate valuable potential for providing frontline clinicians with data-driven, evidence-based tools to guide time-sensitive prognosis evaluations and care decisions for poisoned patients in need of hemodialysis. Further large-scale multi-center studies are warranted to validate the efficacy of these models across diverse populations.

Use of extracorporeal therapies to treat life-threatening intoxications

Toxic ingestions are a significant cause of pediatric morbidity and mortality, with some requiring extracorporeal removal for therapy. Given the emergent and life-threatening nature of such scenarios, it is paramount that clinicians caring for intoxicated children be familiar with the subject. This review summarizes the following: (a) the properties of a substance which lend it amenable to removal; (b) the current extracorporeal treatment modalities available for such removal (of which hemodialysis is typically the ideal choice); (c) an introduction and framework to use a quick reference guide from the Extrip organization, which has a website available to guide clinicians' rapid decisions; and (d) new membranes/approaches that may optimize clearance of certain intoxications.

Management of acute carbamazepine poisoning: A narrative review

Standard management protocols are lacking and specific antidotes are unavailable for acute carbamazepine (CBZ) poisoning. The objective of this review is to provide currently available information on acute CBZ poisoning, including its management, by describing and summarizing various therapeutic methods for its treatment according to previously published studies. Several treatment methods for CBZ poisoning will be briefly introduced, their advantages and disadvantages will be analyzed and compared, and suggestions for the clinical treatment of CBZ poisoning will be provided. A literature search was performed in various English and Chinese databases. In addition, the reference lists of identified articles were screened for additional relevant studies, including non-indexed reports. Non-peer-reviewed sources were also included. In the present review, 154 articles met the inclusion criteria including case reports, case series, descriptive cohorts, pharmacokinetic studies, and in vitro studies. Data on 67 patients, including 4 fatalities, were reviewed. Based on the summary of cases reported in the included articles, the cure rate of CBZ poisoning after symptomatic treatment was 82% and the efficiency of hemoperfusion was 58.2%. Based on the literature review, CBZ is moderately dialyzable and the recommendation for CBZ poisoning is supportive management and gastric lavage. In severe cases, extracorporeal treatment is recommended, with hemodialysis as the first choice.

Successful treatment of 5-fluorouracil toxicosis with hemodialysis

OBJECTIVE

To describe the successful treatment of lethal dose 5-fluorouracil (5-FU) toxicosis using hemodialysis.

CASE SUMMARY

A 4-month-old intact female Golden Retriever was presented to the emergency department after ingesting 20 g of 5% 5-FU cream. The puppy developed refractory seizures and became comatose with uncontrolled tonic-clonic convulsions. Because of the low molecular weight and minimal protein binding of 5-FU, a single hemodialysis treatment was employed for detoxification. The puppy improved clinically posttreatment and was successfully discharged 3 days after admission. Postingestion leukopenia and neutropenia occurred but were responsive to treatment with filgrastim. The puppy is neurologically normal and has no lasting effects 1 year postingestion.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first reported case in veterinary medicine of a potentially fatal 5-FU ingestion that has been treated with intermittent hemodialysis.

Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup

Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid-base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong ("we recommend") or weak/conditional ("we suggest"), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.

Use of Iatrogenic Lipid Emulsion and Subsequent Plasmapheresis for the Treatment of Amitriptyline Overdose

Plasmapheresis for the treatment of hypertriglyceridemia is relatively uncommon and mostly reported either in patients experiencing hypertriglyceridemia-induced acute pancreatitis or patients with therapy-resistant familial hypercholesterolemia. Standard therapies for hypertriglyceridemia include dietary modification and lipid-lowering medication. For severe hypertriglyceridemia, the risk of pancreatitis increases significantly as triglyceride levels increase above 1000 mg/dL, and current therapies are unable to reduce triglyceride levels rapidly enough. Here, we report a case of a 48-year-old male patient who presented to the emergency department due to an amitriptyline overdose. In addition to being started on IV sodium bicarbonate therapy, an intravenous 20% fat emulsion bolus at 1.5 mL/kg was administered followed by 0.25 mL/kg/min infusion for 4 hours as a strategy to absorb lipophilic amitriptyline. Two days posttreatment, he was noted to have substantial hypertriglyceridemia (serum triglycerides: 6,475 mg/dL). His amylase was within the normal range at 37 U/L (reference range: 20-100 U/L), his lipase was low at 40 U/L (reference range: 75-390 U/L), and he was without evidence of any clinical sequelae secondary to hypertriglyceridemia (e.g., pancreatitis). Due to the severity of his hypertriglyceridemia, plasmapheresis was initiated urgently for rapid reduction in serum triglyceride levels to prevent pancreatitis and end-organ damage. He underwent a 1-plasma volume exchange with 5% albumin as the replacement fluid. This reduced his triglyceride levels to 185 mg/dL (reference range: 3-149 mg/dL). His symptoms secondary to his amitriptyline overdose were also resolved. Here, we report a 2-step process of intravenous lipid emulsion followed by plasmapheresis for amitriptyline overdose.

Improving Solute Clearances by Hemodialysis

The adequacy of hemodialysis is now assessed by measuring the removal of the single-solute urea. The urea clearance provided by contemporary dialysis is a large fraction of the blood flow through the dialyzer and therefore cannot be increased much further. Other solutes however likely contribute more than urea to the residual uremic illness suffered by hemodialysis patients. We here review methods which could be employed to increase the clearance of nonurea solutes. We will separately consider the clearances of free low-molecular-mass solutes, free larger solutes, and protein-bound solutes. New clinical studies will be required to test the extent to which increasing the clearance on nonurea solutes with these various characteristics can improve patients' health.

Dialysis and Extracorporeal Therapies for Enhanced Elimination of Toxic Ingestions and Poisoning

Poisoning and toxic ingestions cause significant morbidity and mortality worldwide. Extracorporeal therapies such as dialysis, haemoperfusion and plasma exchange are selectively applied to patients with severe intoxications unresponsive to standard interventions and can be lifesaving. Extracorporeal therapies are a complex but fundamental aspect of the practice of nephrology. Without high-quality evidence to guide implementation, an understanding of toxicokinetics and the physiochemical principles of the enhanced elimination techniques is especially important. This review provides a comphrensive, user-friendly outline of the application of extracorporeal therapy in the poisoned patient.

Clinical and Epidemiological Characteristics of Acute Poisoning in Children in Southwestern China: A Review of 1755 Cases from 2014 to 2020

Purpose

Acute poisoning is a major cause of disability and death in children, but there is a lack of large-scale and multicenter epidemiological data on acute poisoning in children.

Patients and Methods

The current study was a retrospective analysis of clinical data from 1755 children aged 0 to 14 years who were hospitalized between 01 January 2014 and 31 December 2020 in southwestern China.

Results

Acute poisoning was common in childhood, particularly in early childhood (607; 34.6%) and preschool (655; 37.3%), and most cases occurred in rural areas (1191; 67.9%). It was more common in boys (934; 53.2%) than in girls (821; 46.8%). In urban areas, poisoning was mainly caused by drugs (266; 47.2%), chemical agents (59; 10.5%), and alcohol (54; 9.6%). In rural areas, it was mainly caused by pesticides (620; 52.1%) and medications (213; 17.9%), the route of poisoning was usually the digestive tract (1671; 95.2%), in most cases the poisoning was accidental (1618; 92.3%), and pesticides (659; 37.5%) and medications (479; 27.3%) predominated. After timely treatment, the majority of patients had no substantial organ damage, sequelae, or disabilities, and mortality was low (17; 1.0%).

Conclusion

Acute poisoning is a frequent accident in childhood, mainly in infants and preschool children, mostly in rural areas, and poisoning mostly occurs via the digestive tract. Family and community education should be conducted to prevent poisoning.

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Hemoperfusion in combination with hemofiltration for acute severe organophosphorus pesticide poisoning: A systematic review and meta-analysis

Background:

Acute severe organophosphorus pesticide poisoning (ASOPP) is one of the major diseases that endanger human life and health. However, the effects of conventional therapy including gastric lavages, mechanical ventilation, muscarinic antagonist drugs, and cholinesterase reactivators were uncertain. This meta-analysis aims to investigate the safety and efficacy of hemoperfusion combined with hemofiltration besides routine therapy for ASOPP.

Materials and Methods:

A comprehensive search for candidate publications was performed through PubMed, Medline, Cochrane Library, WanFang, Chinese Biomedical Literature, and China National Knowledge Infrastructure from database inception to May 12, 2020. The retrieved studies were screened by the predefined inclusion and exclusion criteria. The data of important end points were extracted. The risk ratio (RR) and weighted mean difference (WMD) were pooled for categorical variables and continuous variables, respectively. Meta-analyses and publication bias were conducted by using STATA software version 15.1.

Results:

A total of 11 randomized controlled trials with 811 patients were included. Compared to conventional therapy group, patients in the hemoperfusion plus hemofiltration group were significantly superior with regard to mortality (RR 0.38, 95% confidence interval [CI] [0.25, 0.57], P < 0.001), total atropine dosing (WMD −147.34 mg, 95% CI [−199.49, −95.18], P < 0.001), duration of mechanical ventilation (WMD −2.34 days, 95% CI [−3.77, −0.92], P < 0.001), cholinesterase recovery time (WMD −2.49 days, 95% CI [−3.14, −1.83], P < 0.001), and length of stay (WMD −4.52 days, 95% CI [−5.31, −3.73], P < 0.001).

Conclusion:

Combined hemoperfusion and hemofiltration was a very safe and effective treatment protocol for ASOPP, not only resulting in significantly decreased mortality but also resulting in reduced total atropine dosing, duration of mechanical ventilation, cholinesterase recovery time, and length of stay.

Extracorporeal blood purification in acutely intoxicated veterinary patients: A multicenter retrospective study (2011-2018): 54 cases

OBJECTIVE

To investigate the clinical outcome and complications associated with extracorporeal blood purification (EBP) using either hemodialysis (HD), hemodialysis and hemoperfusion (HD + HP), or therapeutic plasma exchange (TPE) for the management of acute toxin ingestion in small animals.

DESIGN

Retrospective, multicenter study from January 2011 to July 2018.

SETTING

One university teaching hospital and one private specialty hospital.

ANIMALS

Fifty-one dogs and 3 cats with a history of acute toxin exposure that could lead to severe morbidity and mortality, managed with different EBP techniques.

MAIN RESULTS

Nonsteroidal anti-inflammatory drugs (38/54, 52%), baclofen (8/54, 15%), and ethylene glycol (7/54, 13%) were the most common toxicities treated with EBP. Membrane-based TPE was used most commonly (22/54, 40.7%), followed by HD (17/54, 31.5%) and then HD + HP (15/54, 27.8%). There was an 83.3% (45/54) overall survival, with 88.9% (8/9) of nonsurvivors having clinical signs prior to therapy. One third (18/54) of the patients never developed clinical signs of toxicity. Treatment complications occurred in 44.4% (24/54) of the animals, although only 18.5% (10/54) of these complications, such as mild hypotension, thrombocytopenia secondary to the HP cartridge, facial swelling after plasma transfusion for TPE, bleeding from catheter size secondary to heparinization, or clotting of the system, could be attributed to the EBP treatment. None of the nonsurvivors died because of EBP complications.

CONCLUSIONS

Early initiation of EBP therapy might be considered as an alternative route of decontamination in severe acute toxicities with high potential for significant morbidity and mortality. The survival rate in small animals undergoing EBP is high despite exposure to potential lethal doses of toxins, and survival appears to be more likely if clinical signs of toxicity are not present at the time of EBP. Continued research is warranted with randomized controlled clinical trials to further evaluate the clinical efficacy and benefit of EBP.

Extracorporeal Treatment for Gabapentin and Pregabalin Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup

Toxicity from gabapentin and pregabalin overdose is commonly encountered. Treatment is supportive, and the use of extracorporeal treatments (ECTRs) is controversial. The EXTRIP workgroup conducted systematic reviews of the literature and summarized findings following published methods. Thirty-three articles (30 patient reports and 3 pharmacokinetic studies) met the inclusion criteria. High gabapentinoid extracorporeal clearance (>150mL/min) and short elimination half-life (<5 hours) were reported with hemodialysis. The workgroup assessed gabapentin and pregabalin as "dialyzable" for patients with decreased kidney function (quality of the evidence grade as A and B, respectively). Limited clinical data were available (24 patients with gabapentin toxicity and 7 with pregabalin toxicity received ECTR). Severe toxicity, mortality, and sequelae were rare in cases receiving ECTR and in historical controls receiving standard care alone. No clear clinical benefit from ECTR could be identified although major knowledge gaps were acknowledged, as well as costs and harms of ECTR. The EXTRIP workgroup suggests against performing ECTR in addition to standard care rather than standard care alone (weak recommendation, very low quality of evidence) for gabapentinoid poisoning in patients with normal kidney function. If decreased kidney function and coma requiring mechanical ventilation are present, the workgroup suggests performing ECTR in addition to standard care (weak recommendation, very low quality of evidence).

Recommendations from the EXTRIP workgroup on extracorporeal treatment for baclofen poisoning

Baclofen toxicity results from intentional self-poisoning ("acute baclofen poisoning") or accumulation of therapeutic dose in the setting of impaired kidney function. Standard care includes baclofen discontinuation, respiratory support and seizure treatment. Use of extracorporeal treatments (ECTRs) is controversial. To clarify this, a comprehensive review of the literature on the effect of ECTRs in baclofen toxicity was performed and recommendations following EXTRIP methods were formulated based on 43 studies. (1 comparative cohort, 1 aggregate results cohort, 1 pharmacokinetic modeling, and 40 patient reports or series). Toxicokinetic data were available for 20 patients. Baclofen's dialyzability is limited by a high endogenous clearance and a short half-life in patients with normal kidney function. The workgroup assessed baclofen as "Moderately dialyzable" by intermittent hemodialysis for patients with normal kidney function (quality of evidence C) and "Dialyzable" for patients with impaired kidney function (quality of evidence C). Clinical data were available for 25 patients with acute baclofen poisoning and 46 patients with toxicity from therapeutic baclofen in kidney impairment. No deaths or sequelae were reported. Mortality in historical controls was rare. No benefit of ECTR was identified in patients with acute baclofen poisoning. Indirect evidence suggests a benefit of ECTR in reducing the duration of toxic encephalopathy from therapeutic baclofen in kidney impairment. These potential benefits were balanced against added costs and harms related to the insertion of a catheter, the procedure itself, and the potential of baclofen withdrawal. Thus, the EXTRIP workgroup suggests against performing ECTR in addition to standard care for acute baclofen poisoning and suggests performing ECTR in toxicity from therapeutic baclofen in kidney impairment, especially in the presence of coma requiring mechanical ventilation.

Improving Clearance for Renal Replacement Therapy

The adequacy of hemodialysis is now assessed by measuring the removal of a single solute, urea. The urea clearance provided by current dialysis methods is a large fraction of the blood flow through the dialyzer, and, therefore, cannot be increased much further. However, other solutes, which are less effectively cleared than urea, may contribute more to the residual uremic illness suffered by patients on hemodialysis. Here, we review a variety of methods that could be used to increase the clearance of such nonurea solutes. New clinical studies will be required to test the extent to which increasing solute clearances improves patients' health.

Oral potassium overdose: a case series

OBJECTIVE

Severe toxicity from ingestions of oral sustained-release potassium is rare. While acute hyperkalaemia requires urgent intervention given the risk of cardiac toxicity, there is a lack of clinical consensus on optimal management. The aim of this study was to characterise the clinical manifestations of acute potassium overdose and its management approach.

METHODS

This is a retrospective case series of patients presenting following oral potassium overdose of ≥6000mg between January 2009 and December 2020 in Queensland, Australia as recorded in the state's Poisons Information Centre database and a tertiary Clinical Toxicology Unit database. Patients were identified from prospective databases maintained by both units and data were extracted from these in addition to medical records.

RESULTS

Thirteen presentations in eleven patients occurred in the twelve-year period. The median age was 35 years (range 14-55 years). The median dose ingested was 6.4 mmol/kg (range 0.9-30.8 mmol/kg). Severe hyperkalaemia >7mmol/L occurred in five patients, four with ingestions ≥60,000mg. All patients with hyperkalaemia received multiple modes of intracellular potassium shifting therapy. Four patients had endoscopic removal of pharmacobezoars. One also underwent whole bowel irrigation. Three presentations were managed with haemodialysis. All patients were discharged home with a median length of stay of 20 h.

CONCLUSION

Aggressive medical therapy to shift potassium into cells appears to be the mainstay of treatment in patients with normal renal function. Early decontamination may limit peak potassium concentrations. It is unclear if haemodialysis provides significant additional benefit in patients with normal renal function.

Extracorporeal treatment for calcium channel blocker poisoning: systematic review and recommendations from the EXTRIP workgroup

BACKGROUND

Calcium channel blockers (CCBs) are commonly used to treat conditions such as arterial hypertension and supraventricular dysrhythmias. Poisoning from these drugs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in the management of CCB poisoning.

METHODS

We conducted systematic reviews of the literature, screened studies, extracted data, summarized findings, and formulated recommendations following published EXTRIP methods.

RESULTS

A total of 83 publications (6 in vitro and 1 animal experiments, 55 case reports or case series, 19 pharmacokinetic studies, 1 cohort study and 1 systematic review) met inclusion criteria regarding the effect of ECTR. Toxicokinetic or pharmacokinetic data were available on 210 patients (including 32 for amlodipine, 20 for diltiazem, and 52 for verapamil). Regardless of the ECTR used, amlodipine, bepridil, diltiazem, felodipine, isradipine, mibefradil, nifedipine, nisoldipine, and verapamil were considered not dialyzable, with variable levels of evidence, while no dialyzability grading was possible for nicardipine and nitrendipine. Data were available for clinical analysis on 78 CCB poisoned patients (including 32 patients for amlodipine, 16 for diltiazem, and 23 for verapamil). Standard care (including high dose insulin euglycemic therapy) was not systematically administered. Clinical data did not suggest an improvement in outcomes with ECTR. Consequently, the EXTRIP workgroup recommends against using ECTR in addition to standard care for patients severely poisoned with either amlodipine, diltiazem or verapamil (strong recommendations, very low quality of the evidence (1D)). There were insufficient clinical data to draft recommendation for other CCBs, although the workgroup acknowledged the low dialyzability from, and lack of biological plausibility for, ECTR.

CONCLUSIONS

Both dialyzability and clinical data do not support a clinical benefit from ECTRs for CCB poisoning. The EXTRIP workgroup recommends against using extracorporeal methods to enhance the elimination of amlodipine, diltiazem, and verapamil in patients with severe poisoning.

Management of pharmaceutical and recreational drug poisoning

BACKGROUND

Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis.

METHODS

A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature.

CONCLUSIONS

The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.

Extracorporeal Treatment for Chloroquine, Hydroxychloroquine, and Quinine Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup

BACKGROUND

Although chloroquine, hydroxychloroquine, and quinine are used for a range of medical conditions, recent research suggested a potential role in treating COVID-19. The resultant increase in prescribing was accompanied by an increase in adverse events, including severe toxicity and death. The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup sought to determine the effect of and indications for extracorporeal treatments in cases of poisoning with these drugs.

METHODS

We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods.

RESULTS

A total of 44 studies (three in vitro studies, two animal studies, 28 patient reports or patient series, and 11 pharmacokinetic studies) met inclusion criteria regarding the effect of extracorporeal treatments. Toxicokinetic or pharmacokinetic analysis was available for 61 patients (13 chloroquine, three hydroxychloroquine, and 45 quinine). Clinical data were available for analysis from 38 patients, including 12 with chloroquine toxicity, one with hydroxychloroquine toxicity, and 25 with quinine toxicity. All three drugs were classified as non-dialyzable (not amenable to clinically significant removal by extracorporeal treatments). The available data do not support using extracorporeal treatments in addition to standard care for patients severely poisoned with either chloroquine or quinine (strong recommendation, very low quality of evidence). Although hydroxychloroquine was assessed as being non-dialyzable, the clinical evidence was not sufficient to support a formal recommendation regarding the use of extracorporeal treatments for this drug.

CONCLUSIONS

On the basis of our systematic review and analysis, the EXTRIP workgroup recommends against using extracorporeal methods to enhance elimination of these drugs in patients with severe chloroquine or quinine poisoning.

A model-based analysis of phenytoin and carbamazepine toxicity treatment using binding-competition during hemodialysis

Hemodialysis (HD) has limited efficacy towards treatment of drug toxicity due to strong drug-protein binding. In this work, we propose to infuse a competitor drug into the extracorporeal circuit that increases the free fraction of a toxic drug and thereby increases its dialytic removal. We used a mechanistic model to assess the removal of phenytoin and carbamazepine during HD with or without binding-competition. We simulated dialytic removal of (1) phenytoin, initial concentration 70 mg/L, using 2000 mg aspirin, (2) carbamazepine, initial concentration 35 mg/L, using 800 mg ibuprofen, in a 70 kg patient. The competitor drug was infused at constant rate. For phenytoin (~ 13% free at t = 0), HD brings the patient to therapeutic concentration in 460 min while aspirin infusion reduces that time to 330 min. For carbamazepine (~ 27% free at t = 0), the ibuprofen infusion reduces the HD time to reach therapeutic concentration from 265 to 220 min. Competitor drugs with longer half-life further reduce the HD time. Binding-competition during HD is a potential treatment for drug toxicities for which current recommendations exclude HD due to strong drug-protein binding. We show clinically meaningful reductions in the treatment time necessary to achieve non-toxic concentrations in patients poisoned with these two prescription drugs.

Osteonecrosis of Femoral Head, An Overlooked Long-Term Complication after Paraquat Intoxication: A Retrospective Cohort Study

With increasing numbers of patients surviving acute intoxication phase, long-term complication after paraquat intoxication is a topic worth exploring, such as osteonecrosis (ON) of femoral head. We reviewed 86 paraquat-intoxicated survivors between 2000 and 2012 in Chang Gung Memorial Hospital, a 3700-bed tertiary hospital in Taiwan. With all the patients underwent same detoxification protocol in the acute stage, 17.4% of paraquat poisoning survivors developed ON of femoral head requiring surgery during follow up. Most of ON episodes occurred within 2 to 4 years after paraquat intoxication and then plateau after 6 years. ON patients exhibited higher SOFA scores than non-ON patients (2.80 ± 2.14 vs. 1.76 ± 1.52, p = 0.028). Furthermore, AKIN scores are also higher in the ON patients than non-ON patients (0.87 ± 1.13 vs. 0.38 ± 0.74, p = 0.040). Multivariate logistic regression showed higher AKIN score and higher partial pressure of carbon dioxide in the blood 48 hours after admission significantly predicted ON of femoral head after paraquat intoxication (p = 0.002 and p = 0.006 respectively). Larger studies with longer follow-up durations are warranted to confirm our finding.

Treatment of ibuprofen intoxication with charcoal haemoperfusion in two dogs

Case history: Two dogs presented separately to the Small Animal Hospital, University of Florida (Gainsville, FL, USA) for ingestion of ibuprofen. The first dog ingested 561.8 mg/kg ibuprofen in addition to paracetamol and caffeine and vomited prior to admission. This patient also received fluid therapy for 8 hours prior to charcoal haemoperfusion. The second dog ingested 500 mg/kg of ibuprofen and the owners induced vomiting with hydrogen peroxide prior to presentation. Due to the severity of clinical signs, both patients were treated with charcoal haemoperfusion.Clinical findings: The concentrations of ibuprofen in the blood of the dogs prior to treatment were 478 and 301 mg/L. During the treatment ibuprofen concentrations were reduced by 95.8% and 45.5%, respectively, with no treatment side effects and minimal clinical signs after treatment.Diagnosis: Toxicity due to ingestion of ibuprofen toxicity that was successfully treated with charcoal haemoperfusion.Clinical relevance: In the cases described here minimal benefit was seen after 3 hours of treatment using one haemoperfusion cartridge. This is in contrast to a previously published report in which dogs were treated for 6 hours with two charcoal haemoperfusion cartridges. This suggests that one cartridge may be sufficient. The amount of ibuprofen ingested was not a reliable predictor of the concentration in blood at the initiation of treatment. Charcoal haemoperfusion is an effective means of reducing plasma concentrations of ibuprofen, however, its use may be limited by its cost and availability.

Renal Replacement Therapy in the ICU

OBJECTIVES

The incidence of acute kidney injury in critically ill patients is increasing steeply. Acute kidney injury in this setting is associated with high morbidity and mortality. There is no doubt that renal replacement therapy for the most severe forms of acute kidney injury can be life saving, but there are a number of uncertainties about the optimal application of renal replacement therapy for patients with acute kidney injury. The objective of this synthetic review is to present current evidence supporting best practices in renal replacement therapy for critically ill patients with acute kidney injury.

DATA SOURCES

We reviewed literature regarding timing of initiation of renal replacement therapy, optimal vascular access for renal replacement therapy in acute kidney injury, modality selection and dose or intensity of renal replacement therapy, and anticoagulation during renal replacement therapy, using the following databases: MEDLINE and PubMed. We also reviewed bibliographic citations of retrieved articles.

STUDY SELECTION

We reviewed only English language articles.

CONCLUSIONS

Current evidence sheds light on many areas of controversy regarding renal replacement therapy in acute kidney injury, providing a foundation for best practices. Nonetheless, important questions remain to be answered by ongoing and future investigation.

Extracorporeal treatment in children with acute severe poisoning

Acute poisoning in children is a clinical emergency. Prompt and effective treatment is critical for life-threatening poisoning. Extracorporeal treatment (ECTR) is a practical option for enhancing the elimination of poisons.We conducted a retrospective observational study on 338 children with severe acute poisoning who received ECTR during hospitalization from January 2010 to December 2017. The poisonous substances, utilization of ECTR, adverse reactions to ECTR, and outcomes were recorded.The top 3 poisoning categories, in order of frequency, were found to be pesticides (57.99%), biotoxins (25.15%), and pharmaceuticals (14.20%). Paraquat (35.21%), an organic heterocyclic herbicide with high toxicity to humans, was the most common toxic substance. The main modalities of ECTR use were hemoperfusion (50.59%) and therapeutic plasma exchange (42.60%), followed by continuous renal replacement therapy (4.44%) and hemodialysis (1.18%). There were also 4 patients (1.18%) with a combination of ECTR performed. Adverse events of ECTR included errhysis and hematomas around the catheter exit site, oral cavity bleeding, allergic reactions, hypothermia, hypotension, and blood coagulation. The adverse reactions were mostly mild to moderate and were manageable. During the study period, there were 295 patients (87.28%) who were cured, 9 (2.66%) who experienced some improvement, and 34 (10.06%) who died.ECTR modalities were found to be clinically effective approaches to the treatment of poisoning by pesticides, biotoxins, and pharmaceuticals, indicating they are important modalities in toxicology and treatment, and are well tolerated by children.

Extracorporeal Removal of Poisons and Toxins

Extracorporeal therapies have been used to remove toxins from the body for over 50 years and have a greater role than ever before in the treatment of poisonings. Improvements in technology have resulted in increased efficacy of removing drugs and other toxins with hemodialysis, and newer extracorporeal therapy modalities have expanded the role of extracorporeal supportive care of poisoned patients. However, despite these changes, for at least the past three decades the most frequently dialyzed poisons remain salicylates, toxic alcohols, and lithium; in addition, the extracorporeal treatment of choice for therapeutic removal of nearly all poisonings remains intermittent hemodialysis. For the clinician, consideration of extracorporeal therapy in the treatment of a poisoning depends upon the characteristics of toxins amenable to extracorporeal removal (e.g., molecular mass, volume of distribution, protein binding), choice of extracorporeal treatment modality for a given poisoning, and when the benefit of the procedure justifies additive risk. Given the relative rarity of poisonings treated with extracorporeal therapies, the level of evidence for extracorporeal treatment of poisoning is not robust; however, extracorporeal treatment of a number of individual toxins have been systematically reviewed within the current decade by the Extracorporeal Treatment in Poisoning workgroup, which has published treatment recommendations with an improved evidence base. Some of these recommendations are discussed, as well as management of a small number of relevant poisonings where extracorporeal therapy use may be considered.

Clinical Pearls in Medical Toxicology: Updates Ranging From Decontamination to Elimination

Such as any field of medicine, it is imperative to stay current with the latest advances and treatment modalities in toxicology. With the absence of rigorous randomized controlled trials, many updated guidelines are created by expert consensus and/or case reports and clinical experience. Over the past 10 years, there have been several changes in the management of drug overdoses in light of new data available. Although this is not a comprehensive review of all available antidotes, this article will focus on several important interventions including the use of gastrointestinal decontamination, hyperinsulinemic-euglycemic therapy, methylene blue, intravenous lipid emulsion, hemodialysis, and extracorporeal membrane oxygenation.

[Acute intoxications: markers for screening, diagnosis and therapy monitoring]

Acute poisonings account for a significant proportion of the patient population presenting to intensive care units, whereby mixed drug overdoses and prescription drug overdoses predominate. The aim of this article was to describe indications for screening, diagnosis and therapy monitoring in acute overdoses in the intensive care unit. To conduct this work, a literature search was carried out and a review was written based on guidelines, case reports, expert opinions and scientific publications. Toxidromes are a useful tool for classification of clinical characteristics when the causative agent is initially unknown. Especially in critical care medicine, identifying and quantifying of the causative toxin by enzyme immunoassays, chromatography and mass spectrometry should be attempted. Intensive care treatment of patients with acute overdoses includes not only monitoring and support of vital functions but also methods for primary and secondary elimination of toxins. The indication for the use of extracorporeal procedures should be carefully evaluated and the method should be chosen based on protein binding and molecular size. Lipid emulsion therapy, high-dose insulin euglycaemia therapy and hyperbaric oxygenation are also increasingly used.

Extracorporeal Treatment in the Management of Acute Poisoning: What an Intensivist Should Know?

Extracorporeal treatment (ECTR) represents a treatment modality promoting removal of endogenous or exogenous poisons and supporting or temporarily replacing a vital organ. This article aims to provide a brief overview of the technical aspects and the potential indications and limitations of the different ECTRs, highlighting the important characteristics of poison amenable to ECTR and the most appropriate prescriptions used in the setting of acute poisoning. The various principles that govern poison elimination by ECTR (diffusion, convection, adsorption, and centrifugation) and how components of the ECTR can be adjusted to maximize clearance have also being discussed.